Development and evaluation of a clinical guideline for a paediatric telemedicine service in a low-resource setting

Abstract

Objective: To develop and evaluate a guideline for a paediatric telemedicine and medication delivery service (TMDS).

Methods: A clinical guideline for paediatric telemedicine was derived from the World Health (WHO) Organization Integrated Management of Childhood Illness (IMCI) Handbook. The guideline was deployed at a TMDS in Haiti and evaluated through a prospective cohort study; children ≤10 years were enrolled. For non-severe cases, paired virtual and in-person examinations were conducted at the call centre and household; severe cases were referred to the hospital. The performance of virtual examination components were evaluated by comparison with the paired in-person examination findings (reference).

Results: A total of 391 cases were enrolled. Among the 320 cases with paired examinations, no general WHO danger signs were identified during in-person examinations; 5 cases (2%) required hospital referral due to problem-specific danger signs or other reasons for escalation. Cohen's kappa for the virtual designation of mild cases was 0.78 (95% CI: 0.69 to 0.87). The sensitivity and specificity of a virtually reported fever were 91% (95% CI: 87% to 96%) and 69% (95% CI: 62% to 76%), respectively; the sensitivity and specificity of virtually reported 'fast breathing' were 47% (95% CI: 21% to 72%) and 89% (95% CI: 85% to 94%), respectively. Kappa for 'no' and 'some' dehydration indicated moderate congruence between virtual and in-person examinations (0.69; 95% CI: 0.41 to 0.98). At 10 days, 273 (95%) of the 287 cases reached by phone were better/recovered.

Conclusion: Critical components of the virtual examination (triage, danger signs and dehydration assessment) performed well despite varied performance among the problem-specific components. The study and associated resources represents formative steps towards an evidence-based paediatric telemedicine guideline built on WHO clinical principles. In-person examinations for select cases were important to address limitations with virtual examinations and identify cases for escalation.

Trial registration number: NCT03943654.

Keywords: Health services research.

Figure 1

Telemedicine and medication delivery service workflow. Phone symbol=all families received a follow-up call at 10 days. A version of this figure has been published previously and is published here with permission from The American Journal of Tropical Medicine and Hygiene.

Figure 2

Enrolment and analysis flowchart. Diagram of case enrolment, reasons for study exclusion and inclusion in data analysis. Of the 3216 calls placed, 505 callers were screened for participation. Among the 391 cases enrolled, 320 met inclusion criteria for analyses. ^aFiltered to remove calls from employee phone numbers. ^b1122 unique phone numbers.